FOURTH YEAR

PSYCHIATRY

Doing well is very achievable. Your end of rotation exam is easier to do well in than your summer exam so capitalize on that. The end of rotation exam is clinical so just practice formulating your history, MSE, Mgmt etc. Remember no drug is ever wrong in psychiatry if you can back it up! Summer exam is tough initially but you need to learn past paper questions and practice from the RSCI psych chapters. Other than that use your lecture notes and FOR THE LOVE OF GOD make good notes during your rotation. I didn’t and thought I’d piece it together come summer alas it was difficult. Psychiatry feeds into your final year medicine mark and you’ll need to know psychiatry in final med as well as you can get a psych long case for your final finals. You can never know too much phenomonology or pharmacology. To get your head around psychopharm start by knowing the first line agent for each condition then go from there.

How do the 8 weeks break down?

Week 1: lectures (9-5 most days), a sign in sheet will be put out for every lecture. You will also be asked to sign up for student selected activities and projects.

Weeks 2-6: General psych placement.

You will be assigned to a team, in pairs, in St Patricks, James’ or Tallaght. You will spend Monday, Wednesday and Thursday with your team. There are lectures in general Psychaitry and student presentations on Tuesdays and lectures in child psychiatry on Fridays. Student Case Conferences and TV interviews take place on Wednesday afternoons. During the first 5 weeks students will go on a visit to either the Central Mental Hospital, Dundrum, or to Beechwood School for Autism in Loughlinstown.

Final 2 weeks: Specialist psychiatry placement. You will be assigned, with your partner from weeks 2-6, to a specialist placement for the final two weeks. There are a wide range of specialist placements from eating disorders and old age psychiatry in SPH to liaison psychiatry and forensic psychiatry.

On the last Friday of the rotation the Final Test will take place.

How do the marks break down?

The EMQ exam in June counts for 50% of the marks.

The other 50% of the marks are obtained whilst on rotation.

25% of the marks go for the Final Test

The remaining 25% breakdown between:

Consultant evaluation forms: Your consultants will give you a percentage mark and tick a box regarding attendance and give a brief feedback report.

Case based discussions: Basically a history and mental state exam presentation. You have to do at least 4, 2 can be sighted by a senior registrar and 2 have to be signed by your consultant. You do 3 from your general placement and one from your specialist placement.

Case conference: this is a PowerPoint presentation of a case. You present the history and mental state exam to the group of students in your hospital and a consultant who marks your presentation. Half of the students will have to do a case conference. The other half will have a TV interview.

TV interview: a recorded 15 minute interview with a patient. You are supposed to take a ‘full history’ but most people only got as far as the history of presenting complaint. The purpose is to look at your interviewing style and communication skills. The week after you take the interview a group of students and a consultant will watch the tape and give feedback on the interview.

Project: during the first week you will have to sign up for a project topic in groups of 7. Once you have signed up for the topic you contact your tutor who will give you direction on how to approach the topic. You will give a PowerPoint presentation with your group in front of the class and your tutor, who marks the project. You will be asked some questions about your presentation afterwards.

Student selected activities : everybody must attend two activities from ECT, domiciliary visit or evening on call

Attendance of placement and lectures (80% minimum)

OBS-GYNAE

A subjective, biased account of doing Obs Gynae:

This is a subject where you must understand the basics very well as opposed to getting a broad superficial overview. Learn Impey inside out. There’s very little reason to go beyond Impey and lectures.

An algorithm for learning this subject:

Read Impey -> Oh I think I’ll go read another resource. -> Do you know Impey yet? If no -> Read Impey, if yes -> Read Impey.

Good exam technique is essential for doing well and practicing questions is highly advisable.

If you need a reference use the RCOG guidelines as they are the gold standard for practice. Fundamentally, the powers that be design exams that want you to be clinically competent and actually able to manage these scenarios. You have eight weeks to become an SHO. Good luck.

A more fact based approach:

Andrews Complete Guide to Obstetrics & Gynaecology

Course Structure & Logbook

On the first day you receive a logbook similar in style to the ones we had all through third year. This is handed in on the last day and is worth a few token marks which cant be earned if you lose it. Some people took photos of pages or scanned them in if youre the sort of person to lose things.

The logbook is split into weeks, you spend one week in each different rotation. You do 3 gynae rotations (SJH, AMNCH and the Coombe), delivery suite, neonatology, and 2 antenatal/postnatal weeks. Apart from the gynae ones its all in the Coombe. You stay in the same groups in each area.

For everything other than history taking (clinics, theatre, tutorials etc) you need a signature. You need to have over 80% of these signed to get full marks at the end. For every history taking session listed there is a space in the back for a case summary. These arent graded so just put a simple summary. The ‘New Learningsection underneath is marked and you get more points for having learned lots of things. Remember when you take each history to get the hospital number of the patient as theres a box for this.

Theres a section on one page for ‘Proceduresdone or observed. Most of these you pick up by just turning up to things but you may have to seek out one or two things from doctors or midwives. The midwives are quite receptive to doing some of these if you ask them. You need 80% of these done as well for full marks.

The course mark is broken down as follows: *this may change year to year*

  • 20% end of year MCQs

  • 20% end of year SAQs

  • 5% logbook/TOSBAs (more on these later)

  • 15% end of rotation OSCE

  • 40% end of term long case

TOSBAs

The latest educational acronymic craze, the ‘Team Objective Structured Bedside Assessmentis the continuous assessment part of the course. There are 3 of them (one on each of the antenatal/postnatal weeks and one in gynaecology) and they are essentially a long case split between 6 people. One person takes the history (usually unobserved) of a patient on the ward then presents it to everyone and the next performs a relevant exam (in gynaecology this is just an abdo exam essentially) in front of everyone. You then move off to a side room where the next person gets 5 minutes on differentials/investigations, the next 5 minutes on management plans and the final person gets a related gynaecological/obstetric issue. If the group has 6 people the 6th person does nothing. You do two cases per TOSBA so everyone does every section once. This is marked and graded but you wont get grades until the end of the rotation, just feedback.

Whilst these are mildly stressful compared to anything else on the rotation theyre worth very little and the questions are usually straightforward. The cases are often very common and often the ones covered in the tutorial you had earlier in that week.

OSCE

As Im writing this I was doing the OSCE 2 hours ago so this is particularly fresh in my head. There are 2 identical sets of 3 stations run on the last Thursday evening of the rotation. The first is either an obstetric history taking or gynaecology procedure consenting. The history we had was a lady turning up at her booking visit who had previously had a 38 week stillbirth. Most of the marks came from taking a thorough history of the stillbirth as far as I could tell from Prof Crowleys box ticking. If its a consenting thing, marks are available for talking about the indication, establishing the LMP, any OCP use, previous surgical history, addressing concerns, warning of common and serious complications, how the procedure is done etc.

Station 2 was obstetric examination. A pregnant abdomen model is used, we had a cephalic presentation singleton pregnancy that was large for gestational age. You had to give the causes for an LGA baby.

Station 3 was gynaecology examination. This was using a Cuscos speculum to do a smear test then a bimanual palpation. You can ask Cristina for the keys to the room where the models are kept to practice this. You also had to explain beforehand how a smear test works, what its looking for and whatll happen next.

Delivery Suite

Delivery Suite is three 12 hour shifts. Either 2 days and one night or vice versa. You should arrive early enough to change into scrubs (for guys its in theatre, go through the double doors and its the second or third door on the right, through a small room with a couple of chairs). For girls its inside the delivery suite. Wear comfortable trainers, theres a huge amount of standing.

Youre expected to stay with one mother all the way through her DS visit. If you arent asked to, offer to do the Obs, and take the history of the woman. You have spaces to use this as a case in your logbook. If youre stuck with no patients during the day, ask in theatre about sections. If youre stuck with no patients at night bring a textbook or follow anyone going up for section/manual removal of placenta. Midwives and Clinical Managers vary wildly in their tolerance for medical students so just cross your fingers.

Neonatalogy

Neonatology is part of Paediatrics. Theres a separate bundle of sheets with spaces for signatures for this, these are not required so dont bother filling them in. The baby checks you’re scheduled for are useful for being able to do a neonatal exam. Go to as many as you feel you need to. Dr Sheridan’s tutorial on Thursday is long but she doesnt ask many questions. Everything else is explained clearly by Dr Doolan. The OSCE runs in the last week of the rotation. The questions we got were the same as last year. You get three from the following:

1. Congenital Heart Disease signs

2. Taking a feeding history

3. Normal skin findings

4. Testes examination

5. Measuring the head circumference

6. Tone and 4 reflexes

7. Liver palpation and causes of hepatomegaly

It is a combination of talking about these things and doing them. Its all done on real babies and mothers. This OSCE is easy to pass but difficult to do well in.

Antenatal/Postnatal

Clinics, histories, TOSBAs, easy. Its all done on Our Ladies Ward. The only problem here is the UCD students are prolific and everyone you speak to will have probably already had their history taken unless you go for new patients that day.

Gynaecology

At SJH everything is cancer related so read over that before turning up, youll be expected to know a bit. Dr Gleeson is proactive in theatre for teaching.

In AMNCH its clinics, histories and theatre. Prof Crowleys theatre is essential to turn up to (if she hasnt left by that stage) as she teaches all the way through.

In the Coombe similarly, Prof Crowley has another good theatre session to go to. Theres a TOSBA in this week, we had a prolapse patient and someone post-op from a myomectomy (fibroids).

Other points

You scrub in quite a lot, if youre at the Coombe the room to do this is through the back of theatre 1, so if youre told to go wash when youre in 2 you have to walk all the way through. Its worth knowing generally what the pedicles supporting the uterus are because I got asked this 3 or 4 times in different procedures.

Security once stopped me for not having a badge, just throw a student ID or an SJH/AMNCH badge on when youre wandering around the Coombe.

The canteen opens 10am-11am then 12.40pm-2pm. The Starbucks-esque Coffee Doc (mysteriously also referred to as Café Coombe) is open all day. We got emails about “hanging around” in the canteen. Meh.

There are lockers, bring a padlock to use them.

Clinchs lectures (by his own admission) tend to run on, bring a lunch if you were planning on having it between him and the next person. You need to pre-read for Dalys lectures because hell ask you very specific questions individually and expect reasonable answers. Both these two are more ‘seminar-likeand they dont do handouts. Nadia, Richard Deane, Anne Doolan and Dr Carey have slides on Blackboard & Drive. Prof Murphy has physical handouts only.

GP AND PUBLIC HEALTH

The end of rotation exam is harder than the summer exam. You’ll get a feel for how serious this rotation is when you start it. Don’t flunk your end of rotation exam it does require some attention.

Rotation Breakdown

2 weeks Lectures

2 weeks “inner” GP Rotation (within Co. Dublin)

2 weeks outer GP Rotation

2 weeks Lectures

– Written exam will be the last day of the rotation

(Usually Luce Hall 9:30-11:30am)

Grade Distribution

60% During rotation

– 20% Logbook

– 40% Written Exam (4 extended SAQs)

40% end of year

– 100 T/F MCQs with no negative marking

Overview:

The first day of your GP rotation, you will get a talk from the Public Health and GP directors. They each give a brief overview of their sections of the course.  After this, the secretary, Ailbhe Mealy (AMEALY@tcd.ie), will hand around an envelope containing the contact details of GP attachments. You will select a GP from the envelope for both your Inner and Outer Rotations. After each round, you will have an opportunity to swap GPs if you choose.  After selecting your GPs, Ailbhe will take note of who is assigned to each GP. There is only 1 student assigned to 1 GP.

Inner Rotations:  These placements range in location, however, they are all within Co. Dublin. Some people had to commute for an hour and a half to reach their placements.  You do not receive reimbursement for transport for your inner rotation. Rotations can range from private clinics to GMS clinics. Some are large group practices, while others are small single-GP practices.

Outer Rotations: These are located around the country. Approximately half of the class is located in Co. Donegal, while the remaining half are scattered elsewhere.

 If you are in Donegal, there will be a lecture in Letterkenny the first Friday of your rotation. You will be required to audit 5 diabetic patients, and bring your results to the lecture. The lecture is 3-4 hours and is all about Diabetes.  

You will receive reimbursement for either Travel (€75) OR Accommodation (€150). You are required to submit your original receipt and a reimbursement form to Ailbhe at the end of your rotation.  

Logbook

Throughout your GP placements, you will be required to do small projects. These include a Genetic Disease project, MUPS, Professional Insight, and Practice Population comparison. There is a detailed description of each project in your logbook. These must be typed up and stapled into your logbook.

Practice Log: during your GP placements, you will be required to include the description of 25 patients you encountered. You log their presenting symptoms, the diagnose and disease code. There are boxes to tick if the patient receives a prescription, investigations, advice or a referral.

The logbook is handed in at the end of the rotation. It must be handed in to Ailbhe at Tallaght prior to the exam. No logbooks may be handed in at the exam.

Attendance

Attendance is mandatory and is monitored in every lecture. Sometimes the attendance sheet is handed around to sign, while other times the lecturer takes attendance.  If you have >2 absences, you will be called into Prof. Browne’s office to explain the reason for your absences.  

Lectures

Lectures range in topics, but are primarily about Public Health Policy, Epidemiology and Statistics. There are smaller group seminars scattered through the 4 weeks of lecture. You will be divided into two groups based on alphabetical order and attend your allocated seminars. If you are unable to attend your assigned seminar, you can swap seminar times with a colleague.

 

Written Exam

The written exam is divided into 4 questions. Each question has an underlying theme with multiple components. These questions primarily come from lectures. We had two Public Health related question (alcohol related), an epidemiology question (Relative Risk calculation), and a statistics (interpret a meta-analysis).

PAEDIATRICS

The majority of people use “the Sunflower Book” a.k.a. Illustrated Textbook of Paediatrics which is an appalling book yet the best general book that I’ve looked at. I used a combination of the Sunflower Book, lecture notes, review papers (easy ones) and wikipedia.

There is also a much sought after clinical examination book that is advisable to procure on pdf as the library has only a few copies that will all be reserved around exam time.

Paeds is very focused around the clinical exam. If you can confidently examine a child the marks are yours.

30% of your paeds mark is determined by things you do during the rotation. That’s made of a series of tiny things like 4% neonates exam, 4% case report, 8% OSCE, 10% OSCE. The OSCE is your friend. It’s the same OSCE you have in 2nd year and 3rd year on how to do an examination in meticulous detail. You can make up so much from this 30% and then you’ve a solid base for approaching your summer exams.

Paeds written examination will be different in 2015. So our T/F style exam experience is probably not useful to you.

50% of paeds mark is based on 2 clinical cases taking place at the very end of exam season in either Tallaght, Crumlin or Temple street.

One fifteen minute, one ten minute. It can be anything at all. But being good at examining is KEY.

The cases can be difficult but being able to confidently examine and deal with a potentially difficult child goes a long way.

e.g. *checks for clubbing*

*child pulls hand away and shouts, “NO!”*

Rotation Breakdown

6 weeks Tallaght Hospital

2 weeks Our Lady’s Hospital, Crumlin

The two weeks spent in OLH will be at different times for each group but this will be told on your first day of rotation in Tallaght Hospital. Day one was merely a ‘tour’ of the hospital (as if we have never been there making us look like total nubes) and you are given your timetable for the coming 8weeks. This is broken down day by day telling you exactly where you are and when, so it is very well organised. You are never assigned to an actual team but will attend ward rounds, clinics and tutorials with the various consultants as well as lectures randomly throughout the day. You also will be scheduled for one evening (5-10pm) and one weekend day (make sure there at 9am for ward round usually after which you can go home) on call.

It is recommended to really take advantage of your time in OLH. It is a much larger hospital with a much wider variety of cases to see and due to our limited time there you should really grab hold of any child (and parent) that will talk to you, particularly as Tallaght only has two wards!! There is also one morning spent in the Sunshine Home which is a really nice day out.

Attendance is marked by a sign in sheet which must be signed in before 10am (on the dot) each morning, located upstairs outside the paediatric secretary Siobhan’s office. They do not call you in for poor attendance throughout the rotation, however, they will use it at the end of the year if exams aren’t going so well to see whether you actually attended. Also, just a tip the Tallaght Paeds department is quite small with a limited number of doctors and so the main tutors will recognise people after seeing them a few times, which may or may not help in exams if you have been seen to be attending.

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